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CIGNA ADVANTAGE 3-TIER PRESCRIPTION DRUG LIST
As of July 1, 2018
Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company
887152 k Advantage 3-Tier w DRT 03/18
2
View your drug list online
This document was last updated 09/01/2017.* To see a current list of the medications covered on your plan’s drug list, visit:
Questions? – Call the toll-free number on the back of your Cigna ID card. We’re here to help.
The myCigna® website – Once you’re registered, log in and select Estimate Health Care Costs, then select Get drug costs.
Cigna.com/druglist – Select your drug list name – Advantage 3 Tier – from the drop down menu.
Table of Contents
Your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Medications that are not covered 17
Prescription drug list FAQs 26
Exclusions and limitations 29
Getting started
* Drug list created: originally created 03/01/2011 Last updated: 09/01/2017, for changes that were effective 01/01/2018
Next planned update: 09/01/18, for changes that will be effective 01/01/2019
TIER 1$
TIER 2$$
BLOOD PRESSURE/HEART MEDICATIONS
afeditab CRamlodipine besylateamlodipine besylate-benazeprilamlodipine-valsartanamlodipine-valsartan-HCTZatenololatenolol-chlorthalidonebenazepril benazepril-HCTZcandesartan cilexetilcartia XTcarvedilolclonidinedigitekdigoxdigoxindiltiazem ERdiltiazem CDdiltiazem dilt-XRenalapril flecainide acetatehydralazine irbesartanisosorbide mononitrat
Berinert* (PA)BidilBystolicCinryze* (PA)Coreg CRCozaar (ST)Diovan (ST)Diovan HCT (ST)Edarbi (ST)Edarbyclor (ST)ExforgeExforge HCTFirazyr* (PA)HemangeolInderal LAInderal XLInnopran XLLotrelMicardis (ST)MultaqNitro-durNitrolingualNitromistNitronalNitrostatNorthera* (PA)NorvascRanexa (ST)TekturnaTekturna HCT
Your prescription drug list
Medications are grouped by the condition they treat
Medications that have coverage requirements will have an abbreviation listed next to them
Medications are listed in alphabetical order within each column
Brand name medications are capitalized
Generic medications are lowercase
Specialty medications have an asterisk (*) listed next to them
Tier (coverage/cost level) gives you an idea of how much you may pay for a medication
This document shows the most commonly prescribed medications covered on the Advantage Prescription Drug List as of July 1, 2018.1 All of these medications are approved by the U.S. Food and Drug Administration (FDA). The Advantage Prescription Drug List excludes medications in two drug classes that are available over-the-counter without a prescription. These include medications commonly used to treat:
› Heartburn and stomach acid conditions (ex. Nexium, Prilosec and any generics) and
› Allergies (ex. Allegra, Clarinex, Xyzal and any generics) Medications are listed by the condition they treat, then listed alphabetically within tiers (or coverage/cost levels). It’s important to know that this is not a complete list of covered medications, and not all of the medications listed here may be covered by your specific plan. You should log in to the myCigna website or app or check your plan materials to learn more about the medications your plan covers.
How to read your drug listUse the sample chart below to help you understand this drug list. This chart is just an example. It may not show how these medications are actually covered on the Advantage Prescription Drug List.
3
This chart is just a sample. It may not show how these medications are actually covered on the Advantage Prescription Drug List.
4
Brand name medications are capitalized
In this drug list, brand name medications are capitalized and generic medications are lowercase.
Specialty medications are marked with an asterisk
Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. In this drug list, specialty medications are marked with an asterisk (*). Some plans may cover these medications on a specialty tier, may limit you to a 30-day supply and/or require the use of a preferred specialty pharmacy. Log in to the myCigna website or app or check your plan materials to learn more about how your plan covers specialty medications.
Tiers
Covered medications are divided into tiers, or cost levels. Typically, the higher the tier, the higher the price you’ll pay to fill the prescription.
Abbreviations next to medications
Some medications on your drug list have additional requirements before they may be covered by your plan.* This helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right situation. These medications will have an abbreviation next to them in the drug list. Here’s what each of the abbreviations mean.
› Tier 1 – Typically Generics (Lower-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Higher-cost medication) $$$
(PA) Prior Authorization – Cigna will review information provided by your doctor to make sure you meet coverage guidelines for the medication. If approved, your plan will cover the medication.
(ST) Step Therapy – The Step Therapy program encourages the use of lower-cost medications (generics and preferred brands) to treat certain conditions. Certain high-cost brand medications require Step Therapy. This means your plan requires you to try a lower-cost alternative first, before the higher-cost brand may be covered (unless you receive approval from Cigna).
(QL) Quantity Limits – For some medications, your plan will only cover up to a certain amount over a certain length of time. For example, 30mg per day for 30 days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
(AGE) Age Requirements – You must be within a specific age range for your plan to cover the medication.
* This may not apply to you because not all plans require prior authorization, quantity limits and/or Step Therapy. Please log in to the myCigna website or app or check your plan materials to find out if your plan includes these specific coverage requirements.
5
No cost-share preventive medications are marked with a plus sign
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires that most plans cover certain categories of medications and other products as preventive care services. In this drug list, medications with a plus sign (+) next to them may be available to you at no cost-share (copay, coinsurance and/or deductible). Log in to the myCigna website or app or check your plan materials to learn more about how your plan covers preventive medications.
Plan exclusions
Some medications shown in this drug list may not be covered by your specific plan. For example, your plan may not cover medications used for weight loss or to treat infertility. In this drug list, these medications have a carat (^) next to them. Log in to the myCigna website or app or check your plan materials to find out if your plan excludes the medication.
How to find your medication on the drug list
Find your condition in the alphabetical list below. Then go to that page to see the covered medications available to treat the condition.
Condition Page
AIDS/HIV 6
ALLERGY/NASAL SPRAYS 6
ALZHEIMER’S DISEASE 6
ANXIETY/DEPRESSION/BIPOLAR DISORDER
6
ASTHMA/COPD/RESPIRATORY 6
ATTENTION DEFICIT HYPERACTIVITY DISORDER
7
BLOOD MODIFIERS/BLEEDING DISORDERS 7
BLOOD PRESSURE/HEART MEDICATIONS 7
BLOOD THINNERS/ANTI-CLOTTING 7
CANCER 8
CHOLESTEROL MEDICATIONS 8
CONTRACEPTIVE PRODUCTS 8–10
COUGH/COLD MEDICATIONS 10
DENTAL PRODUCTS 10
DIABETES 10
DIURETICS 11
EAR MEDICATIONS 11
EYE CONDITIONS 11
Condition Page
FEMININE PRODUCTS 11
GASTROINTESTINAL/HEARTBURN 11
HORMONAL AGENTS 12
INFECTIONS 12, 13
INFERTILITY 13
MISCELLANEOUS 13
MULTIPLE SCLEROSIS 13
NUTRITIONAL/DIETARY 13
OSTEOPOROSIS PRODUCTS 14
PAIN RELIEF AND INFLAMMATORY DISEASE 14, 15
PARKINSON’S DISEASE 15
SCHIZOPHRENIA/ANTI-PSYCHOTICS 15
SEIZURE DISORDERS 15
SKIN CONDITIONS 15, 16
SLEEP DISORDERS/SEDATIVES 16
SMOKING CESSATION 16
SUBSTANCE ABUSE 16
TRANSPLANT MEDICATIONS 16
URINARY TRACT CONDITIONS 16
6
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
AIDS/HIV
abacavir-lamivudine*
lamivudine-zidovudine*
nevirapine ER*nevirapine*
Atripla*Intelence*Isentress HD*Isentress*Norvir capsule, solution*
Prezista*Selzentry*Truvada*
Complera*Descovy*Evotaz*Genvoya*Norvir tablet*Odefsey*Prezcobix*Reyataz*Stribild*Sustiva*Tivicay*Triumeq*Viread*
ALLERGY/NASAL SPRAYS
AdyphrenAdyphren Ampazelastinecromolyn cyproheptadineepinephrine auto-injector (QL)
fluticasonehydroxyzineipratropiummometasone spray (QL)
olopatadinePhenerganpromethazine
Clarinex-D 12 HourEpinephrineSnap-VEPIsnapKarbinal ERRyvent
ALZHEIMER’S DISEASE
donepezildonepezil ODTmemantinepyridostigminepyridostigmine ERrivastigmine
MestinonNamendaNamenda XRNamenda XR titration pack (QL)
Namzaric (QL)Regonol
ANXIETY/DEPRESSION/BIPOLAR DISORDER
alprazolamalprazolam ERalprazolam intensolalprazolam ODTalprazolam XRamitriptylinebupropion (QL)bupropion SR (QL)buspirone
Effexor XR (ST, QL)Fetzima (ST, QL)Forfivo XL (ST, QL)OnfiProzac (ST, QL)Sarafem (ST)Trintellix (ST)Viibryd (ST)Wellbutrin SR (ST, QL)
TIER 1$
TIER 2$$
TIER 3 $$$
ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont)
citalopram (QL)clomipraminedesvenlafaxine 50mg
desvenlafaxine ER 25mg, 100mg(QL)
diazepamduloxetine (QL)escitalopram (QL)fluoxetine (QL)fluoxetine DR (QL)fluvoxamine (QL)fluvoxamine ER (QL)lorazepamlorazepam intensolmirtazapineparoxetine (QL)paroxetine CR (QL)paroxetine ER (QL)sertraline (QL)trazodonevenlafaxine (QL)venlafaxine ER (QL)
XanaxXanax XRZoloft (ST, QL)
ASTHMA/COPD/RESPIRATORY
albuterolbudesonideipratropium-albuterol
levalbuterol HFAmontelukast
Advair DiskusAdvair HFAAnoro ElliptaAtrovent HFABreo ElliptaIncruse ElliptaProAir HFAProAir RespiClickQVARQVAR RedihalerStriverdi RespimatSymbicortTrelegy Ellipta (ST)
Adcirca* (PA)Adempas* (PA)Aralast NP* (PA)Combivent Respimat
Daliresp (QL)Fasenra* (PA)Glassia* (PA)Kalydeco* (PA)Letairis* (PA)Nucala* (PA)Ofev* (PA)Opsumit* (PA)Orenitram ER* (PA)Orkambi* (PA)PulmicortPulmozyme* (PA)Remodulin* (PA)Revatio* (PA)Tracleer* (PA)Tyvaso* (PA)Uptravi* (PA)Xolair* (PA)
7
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
ATTENTION DEFICIT HYPERACTIVITY DISORDER
atomoxetinedexmethylphenidatedexmethylphenidate ER
dextroamphetamine-amphetamine ER
dextroamphetamine-amphetamine
guanfacine ERMetadate ERmethylphenidatemethylphenidate CDmethylphenidate ERmethylphenidate LA
Adderall (ST)Adderall XR (ST)Adzenys ER (ST)Adzenys XR-ODT (ST)
Aptensio XR (ST)Concerta (ST)Dyanavel XR (ST)Evekeo (ST)Focalin (ST)Focalin XR (ST)Methylin (ST)Quillichew ER (ST)Quillivant XR (ST)Ritalin (ST)Ritalin LA (ST)Strattera
BLOOD MODIFIERS/BLEEDING DISORDERS
tranexamic acid* Aranesp* (PA)DroxiaGranix*Neulasta* (PA)Soliris* (PA)Zarxio*
Amicar*Bebulin* (PA)Ceprotin*Epogen* (PA)Procrit* (PA)Promacta* (PA)
BLOOD PRESSURE/HEART MEDICATIONS
Afeditab CRamlodipineamlodipine-benazepril
amlodipine-olmesartan
amlodipine-valsartan
amlodipine-valsartan-HCTZ
Aspir 81+
Aspir-Low+
atenololatenolol-chlorthalidone
benazeprilbenazepril-HCTZBufferin+
candesartanCartia XTcarvedilolclonidineDigitekDigox
Corlanor (PA)Entresto (PA)
Bayer Chewable Aspirin+
Berinert* (PA)BiDil (QL)Cardizem LACinryze* (PA)Coreg CREpaned (ST)Firazyr* (PA)Haegarda* (PA)HemangeolInderal LAInderal XLInnopran XLMultaqNitro-DurNitrolingualNitromistNitrostatNorthera* (PA)NorvascRanexa (ST, QL)TiazacTikosyn (QL)
TIER 1$
TIER 2$$
TIER 3 $$$
BLOOD PRESSURE/HEART MEDICATIONS (cont)
Digoxindiltiazemdiltiazem CDdiltiazem ERDilt-XRdofetilide (QL)doxazosinEcotrin+
EcPirin+
enalaprilflecainidehydralazineirbesartanisosorbide isosorbide ERlabetalollisinoprillisinopril-HCTZlosartan losartan-HCTZMatzim LAmetoprololnadololnifedipinenifedipine ERolmesartan olmesartan-amlodipine-HCTZ
olmesartan-HCTZpropafenonepropafenone ERpropranololpropranolol ERramiprilTaztia XTtelmisartantelmisartan-HCTZtri-buffered aspirin+
valsartanvalsartan-HCTZverapamilverapamil ERverapamil SR
BLOOD THINNERS/ANTI-CLOTTING
aspirin-dipyridamole ER
clopidogrelenoxaparin* (QL)fondaparinux* (QL)Jantovenprasugrelwarfarin
BrilintaEliquisXarelto
CoumadinEffientFragmin* (QL)PradaxaSavaysaZontivity
8
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
CANCER
anastrozolebexarotene* (PA)capecitabine* (PA)exemestaneimatinib* (PA)letrozolemercaptopurinemethotrexate*raloxifene+
tamoxifen+ temozolomide* (PA)
Avastin* (PA)Fareston (QL)GleostineHerceptin* (PA)Intron A* (PA)Nexavar* (PA)Revlimid* (PA)Rituxan* (PA)Sprycel* (PA)Sutent* (PA)Tarceva* (PA)Trexall*Tykerb* (PA)Valstar*
Afinitor* (PA)Alecensa* (PA)ArimidexBosulif* (PA)Cabometyx* (PA)Cometriq* (PA)Cotellic* (PA)Erivedge* (PA)Gazyva* (PA)Gilotrif* (PA)Gleevec* (PA)Ibrance* (PA)Iclusig* (PA)Imbruvica* (PA)Inlyta* (PA)Jakafi* (PA)Kadcyla* (PA)Kisqali* (PA)Lenvima* (PA)Lonsurf* (PA)Lynparza* (PA)Mekinist* (PA)Ninlaro* (PA)Perjeta* (PA)Pomalyst* (PA)Purixan*Rubraca* (PA)Stivarga* (PA)Sylatron* (PA)Tafinlar* (PA)Tagrisso* (PA)Targretin* (PA)Tecentriq* (PA)Verzenio* (PA)Votrient* (PA)Xalkori* (PA)Xtandi* (PA)Zejula* (PA)Zelboraf* (PA)Zytiga* (PA)
CHOLESTEROL MEDICATIONS
atorvastatin atorvastatin 10mg, 20mg+
ezetimibefenofibratefenofibric acidfluvastatin 20mg, 40mg+
Praluent* (PA)Repatha* (PA)
Kynamro* (PA)VascepaWelcholZetia
TIER 1$
TIER 2$$
TIER 3 $$$
CHOLESTEROL MEDICATIONS (cont)
fluvastatin ER 80mg+
lovastatin 20mg, 40mg+
niacin ERNiacoromega-3 acid ethyl esters
pravastatin+ rosuvastatin rosuvastatin 5mg, 10mg+
simvastatin 10mg, 20mg, 40 mg+
simvastatin 80mg (QL)
Triklo
CONTRACEPTIVE PRODUCTS
All contraceptive products may be covered if you meet specific gender requirements.
Aftera+
Altavera+
Alyacen+
Amethia Lo+
Amethia+
Amethyst+
Apri+
Aranelle+
Ashlyna+
Aubra+
Aviane+
Azurette+
Balziva+
Bekyree+
Blisovi 24 FE+
Blisovi FE+
Briellyn+
Camila+
Camrese Lo+
Camrese+
Caziant+
Chateal+
Cryselle+
Cyclafem+
Cyred+
Dasetta+
Daysee+
Deblitane+
Delyla+
BeyazLo Loestrin FETaytulla
Caya Contoured+
Ella+
Estrostep FEFC2 Female Condom+
Femcap+
Kyleena*LoSeasoniqueMinastrin 24 FEMirena*NuvaRingSeasoniqueSkyla*Wide Seal Diaphragm+
9
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
CONTRACEPTIVE PRODUCTS (cont)
All contraceptive products may be covered if you meet specific gender requirements.
desogestrel-ethinyl estradiol+
drospirenone-ethinyl estradiol-levomefibrate+
drospirenone-ethinyl estradiol+
Econtra EZ+
Elinest+
Emoquette+
Enpresse+
Enskyce+
Errin+
Estarylla+
ethynodiol-ethinyl estradiol+
Falmina+
Fayosim+
Femynor+
Gianvi+
Gildagia+
Gynol II+
Heather+
Introvale+
Isibloom+
Jencycla+
Jolessa+
Jolivette+
Juleber+
Junel FE+
Junel FE 24+
Junel+
Kaitlib FE+
Kariva+
Kelnor 1-35+
Kimidess+
Kurvelo+
Larin 24 FE+
Larin FE+
Larin+
Larissia+
Leena+
Lessina+
Levonest+
TIER 1$
TIER 2$$
TIER 3 $$$
CONTRACEPTIVE PRODUCTS (cont)
All contraceptive products may be covered if you meet specific gender requirements.
levonorgestrel-ethinyl estradiol+
Levora-28+
Lillow+
Loryna+
Low-Ogestrel+
Lutera+
Lyza+
Marlissa+
medroxyprogesterone 150mg/ml+
Melodetta 24 FE+
Mibelas 24 FE+
Microgestin FE+
Mono-Linyah+
Mononessa+
My Way+
Myzilra+
Necon 0.5/35+
Necon 7/7/7+
Nikki+
Nora-BE+
norethin-eth estradiol-ferrous fumarate+
norethindrone-ethinyl estradiol+
norethindrone+
norgestimate-ethinyl estradiol+
Norgestrel/ethinyl estradiol+
Norlyda+
Norlyroc+
Nortrel+
Nuvaring+
Ocella+
Opcicon One-Step+
Option 2+
Orsythia+
Philith+
Pimtrea+
Pirmella+
Portia+
Previfem+
Quasense+
Rajani+
10
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
CONTRACEPTIVE PRODUCTS (cont)
All contraceptive products may be covered if you meet specific gender requirements.
Reclipsen+
Rivelsa+
Setlakin+
Sharobel+
Sprintec+
Sronyx+
Syeda+
Tarina FE+
Tilia FE+
Tri Femynor+
Tri-Estarylla+
Tri-Legest FE+
Tri-Linyah+
Tri-Lo-Estarylla+
Tri-Lo-Marzia+
Tri-Lo-Sprintec+
Tri-Previfem+
Tri-Sprintec+
Trinessa+
Trinessa Lo+
Trivora-28+
VCF+
Velivet+
Vestura+
Vienva+
Viorele+
Vyfemia+
Wera+
Wymzya FE+
Xulane+
Zarah+
Zenchent+
Zovia 1-35e+
Zovia 1-50e+
COUGH/COLD MEDICATIONS
benzonatateBromfed DMbrompheniramine-pseudoephedrine-DM
hydrocodone-chlorpheniramine ER (QL)
Flowtuss (QL)Hycofenix (QL)Tuzistra XR (QL)
TIER 1$
TIER 2$$
TIER 3 $$$
COUGH/COLD MEDICATIONS (cont)
hydrocodone-homatropine (QL)
Hydromet (QL)promethazine-codeine (QL)
Tussigon (QL)
DENTAL PRODUCTS
chlorhexidine rinseDenta 5000 PlusDentaGeldoxycyclinefluorideFluoridexFluoritabFlura-DropsLudent FluorideOraloneParoexPeridexPeriogardSFSF 5000 Plussodium fluoridetriamcinolone paste
Clinpro 5000FluorabonPrevidentPrevident 5000
DIABETES
glimepirideglipizideglipizide ERglipizide XLmetformin (generic of Glucophage XR)
metformin ER
Basaglar Kwikpen Bydureon (QL)ByettaFarxigaGlucaGen Hypokit (QL)
GlyxambiHumalogHumulin JanumetJanumet XRJanuviaJardianceLevemirOneTouch test strips and meters
Soliqua SymlinPen SynjardySynjardy XRTresiba Trulicity (QL)Xigduo XRXultophy
CyclosetGlucagon Emergency Kit (QL)
GlucophageGlucophage XRKorlym* (PA)RiometVGo
11
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
DIURETICS
acetazolamideeplerenonefurosemidehydrochlorothiazidespironolactonetriamterene-HCTZ
DiurilDyazideDyreniumLasixMaxzideSamsca*
EAR MEDICATIONS
neomycin-polymyxin-hydrocortisone
ofloxacin
Cipro HCCiprodex
EYE CONDITIONS
azelastinebacitracinbrimonidineciprofloxacindorzolamide-timololerythromycinfluorometholonegatifloxacinketorolaclatanoprostmoxifloxacinneomycin-polymyxin-dexamethasone
ofloxacinolopatadinepolymyxin B sul-trimethoprim
prednisolonetimololtobramycintobramycin-dexamethasone
RestasisSimbrinzaTravatan ZXiidra
AcuvailAlphagan PAlrexAzasiteAzoptBesivanceBetimolBetoptic SBromsiteCombiganCosopt PFCystaran* (QL)DurezolEylea* (PA)IlevroIluvien*LotemaxLucentis* (PA)MoxezaNevanacOzurdex*ProlensaTobradexTobradex STVigamoxXalatanZioptan (ST, QL)ZirganZylet
FEMININE PRODUCTS
Fem pHGynazole 1miconazole 3terconazole
AVCRelagardTerazol 7
TIER 1$
TIER 2$$
TIER 3 $$$
GASTROINTESTINAL/HEARTBURN
Alophen+
alosetron*Anucort-HCbalsalazideBisa-Lax+
bisacodyl+
chlordiazepoxide-clidinium
Clearlax+
dicyclominediphenoxylate-atropine
dronabinolDucodyl+
Gavilax+
Gavilyte-C+
Gavilyte-G+
Gavilyte-N+
GentleLax+
Glycolax+
HealthyLax+
Hemmorex-HChydrocortisone suppository
lansoprazole-amoxicillin-clarithromycin (combo pak)
LaxaClear+
mesalamine 1.2gm tablet, enema
metoclopramidemetoclopramide ODT
Natura-Lax+
ondansetronondansetron ODTPEG 3350-electrolyte+
PEG-Prep+
PhenadozPowderlax+
promethazine suppository
PrometheganPurelax+
Smooth LAX+
sucralfateTriLyte with flavor packets+
ursodiol
AprisoCreonPentasaZenpep
Akynzeo* (PA, QL)AmitizaCanasaCarafateCholbam* (PA)ClenpiqCoLyte with flavor packets+
Correctol+
DiclegisDonnatalDulcolax+
Entyvio* (PA)Gattex* (PA)Gialax+
GoLYTELY+
KristaloseLialda (ST)LinzessMiralax+
Movantik (PA)MoviPrep+
Nulytely with flavor packets+
Ocaliva* (PA)OsmoPrep+
PancreazePertzyePrepopik+
Ravicti* (PA)RectivRelistor (PA)Sancuso (PA, QL)Sensipar*sfRowasaSucraid*Suprep+
Sustol (PA)Symproic (PA)Transderm-ScopVarubi* (PA, QL)ViberziViokace
12
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
HORMONAL AGENTS
Amabelzbudesonide ECcabergoline (QL)CovaryxCovaryx H.S.desmopressin*dexamethasoneEEMTEEMT H.S.estradiol (QL)estradiol-norethindrone
estrogen-methyltestosterone
levothyroxine Levoxylliothyronine LocortmedroxyprogesteronemethimazolemethylprednisoloneMillipredMillipred DPMimveyMimvey LoNature-ThroidnorethindroneNP Thyroidprednisoloneprednisolone ODTprednisoneprednisone intensolprogesteronetestosterone (PA, QL)testosterone cypionate
thyroidUnithroid 75mgWesthroidWP ThyroidYuvafem (QL)
AndroGel 1.62% (PA, QL)
DuaveeForteo*Humatrope* (PA)PremarinPremphasePremproSandostatin LAR Depot* (PA)
Serostim* (PA)Zorbtive* (PA)
ActivellaAlora (QL)Androderm (PA, QL)AndroGel 1% (PA, QL)
AngeliqArmour ThyroidAveed* (PA)ClimaraClimara ProCombipatchCytomelDeltasoneDepo-TestosteroneDivigelElestrinEmflaza* (PA)Entocort ECEstraceEstring (QL)EstrogelEvamistFemringGanirelix*H.P. Acthar* (PA)Levo-TLupron Depot* (PA)Menostar (QL)Minivelle (QL)Natpara* (PA)OsphenaRayaldeeSomatuline Depot* (PA)
Somavert* (PA)Striant (PA, QL)Supprelin LA* (PA)SynthroidTestopel (PA)Thyrogen*TirosintUnithroidVagifem (QL)Vivelle-Dot (QL)
TIER 1$
TIER 2$$
TIER 3 $$$
INFECTIONS
acycloviramoxicillinamoxicillin-clavulanate ER
amoxicillin-clavulanate
atovaquoneatovaquone-proguanil
Avidoxyazithromycincefdinircefiximecefuroximecephalexinciprofloxacinclarithromycinclarithromycin ERclindamycinCoreminodapsoneDoxy 100doxycyclinedoxycycline IR-DREmvermentecavir*erythromycinfamciclovirfluconazolehydroxychloroquineitraconazolelevofloxacinmetronidazoleminocyclineminocycline ERMondoxyne NLMorgidoxmoxifloxacinnitrofurantoinnystatinOkebooseltamivir (QL)penicillin Vsulfamethoxazole-trimethoprim
terbinafinetetracyclinetinidazoletobramycin*
Baraclude solution*
Epclusa* (PA)Harvoni* (PA)Kitabis Pak*Mavyret* (PA)Pegasys* (PA)Sovaldi* (PA)Tamiflu suspension (QL)
Thalomid* (PA)Vosevi* (PA)
AlbenzaAliniaBactrimBactrim DSBaraclude tablet*BiltricideCayston*CeftinCiproCleocinClindesseCresemba (PA)Daraprim* (PA)Dificid (PA)E.E.S. 400Eryped 200Ery-TabMinocinMonurolNoxafilPCEPegIntron* (PA)PlaquenilSulfatrimSupraxSynagis* (PA)Tamiflu capsule (QL)Tobi Podhaler*Uretron D-SUribelUrogesic-BlueUTAValtrexVemlidy*VibramycinXifaxanZepatier* (PA)ZithromaxZmax
13
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
INFECTIONS (cont)
valacyclovirvalganciclovirvancomycinvandazolevoriconazole (PA)
INFERTILITY
clomiphene Follistim AQ* CrinoneEndometrinMakena* (PA)Menopur*
MISCELLANEOUS
disulfiramNebuSal 3%PulmoSalsodium chloridetetrabenazine* (PA)
Cerdelga* (PA)Nityr* (PA)TechLITE lancets
Addyi (QL)Botox* (PA)Carbaglu*Cerezyme* (PA)Dysport* (PA)Esbriet* (PA)Exjade*Ferriprox*HyperSalJadenu*Kuvan* (PA)Lumizyme* (PA)Myalept* (PA)Naglazyme* (PA)NebuSal 6%Nuedexta (QL)Orfadin* (PA)Strensiq* (PA)Syprine* (PA)Vimizim* (PA)Vivitrol*VPRIV* (PA)Xenazine* (PA)Xeomin* (PA)Zavesca* (PA)
MULTIPLE SCLEROSIS
glatiramer* (PA)Glatopa* (PA)
Ampyra* (PA)Aubagio* (PA)Avonex* (PA)Betaseron* (PA)Extavia* (PA)Gilenya* (PA)Plegridy* (PA)Rebif* (PA)Tecfidera* (PA)
Lemtrada* (PA)Ocrevus* (PA)Tysabri* (PA)Zinbryta* (PA)
TIER 1$
TIER 2$$
TIER 3 $$$
NUTRITIONAL/DIETARY
B-12 compliancecalcitriolcalciumcyanocobalamin injection
D-Vi-Sol+
D3-2000+
D3-50+
Decara+
Delta D3+
Dialyvite Vitamin D+
Dialyvite Vitamin D3 Max+
FA-8+
folic acidKlor-ConKlor-Con M10, M20Klor-Con Sprinklelanthanum carbonate
levocarnitinemultivitamin with fluoride
multivitamin-iron-fluoride+
Optimal D3+
PNV-DHApolyvitamins-fluoride+
potassium chloridePrena1 Pearlprenatal vitamin+
Prenatal+
Right Step+
sevelamer sodium fluoride+
Super Daily D3+
Thera-D+
tri-vitamin with fluoride-iron+
tri-vitamin with fluoride+
Virt-PN DHAVitajoy Daily D+
vitamin D-400+
vitamin D2vitamin D3+
vitamins A,C,D and fluoride+
Zatean-PN DHA
Fosrenol powderNestabs DHAOB Complete OnePrefera OBPrenate DHA, Elite
Auryxia (QL)Bio-D-Mulsion Forte+
Bio-D-Mulsion+
CitraNatal Concept DHAEscavite D+
Escavite+
Feriva 21-7Ferralet 90Fosrenol tabletIntegra PlusIrospanJust D+
K-Tab ERKlor-Con 10Klor-Con 8Klor-Con M15KPN+
Maximum D3+
MephytonMVC-fluoride+
NascobalOB Complete GoldOptimal D3 M+
Perry Prenatal+
PhoslyraPhysicians EZ Use B-12
Poly-Vi-Flor+
Poly-Vi-Flor With Iron+
Prenate Quflora+
RenagelRenvelaReplesta NX+
Replesta+
Texavite LQ+
Tri-Vi-Flor+
Tristart DHAUrosex+
VelphoroVeltassaVitafolvitaMedMD One RxvitaPearlVP-PNV-DHA
14
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
OSTEOPOROSIS PRODUCTS
alendronate 40mg (QL)
alendronateibandronate*raloxifenerisedronate risedronate DR
Tymlos* Actonel (ST)Fosamax Plus D (ST)Prolia* (PA)Xgeva* (PA)
PAIN RELIEF AND INFLAMMATORY DISEASE
acetaminophen-codeine (PA, QL)
acitretinallopurinolbaclofenbuprenorphine (QL)butalbital-acetaminophen-caffeine-codeine (PA, QL)
butalbital-acetaminophen-caffeine (QL)
carisoprodolcelecoxib (QL)colchicinecyclobenzaprineDermacinRx Empricaine
DermacinRx Prizopak
diclofenac gel (QL)diclofenac ERdiclofenac -misoprostol
dihydroergotamine (QL)
eletriptan (QL)Endocet (PA, QL)etodolacetodolac ERfenoprofen Fenortho (ST)fentanyl patch (PA, QL)
Fioricet (QL)frovatriptan (QL)Glydo
Actemra* (PA)Embeda (PA, QL)Enbrel* (PA)Humira* (PA)Hysingla ER (PA, QL)
Otezla* (PA)Rasuvo* (PA)Remicade* (PA)Stelara* (PA)Xtampza ER (PA, QL)
Abstral (PA, QL)Actiq (PA, QL)Analpram HCBenlysta* (PA)Butrans (QL)Celebrex (ST, QL)Cimzia* (PA)ColcrysCosentyx* (PA)Cuprimine* (PA)Depen* (PA)Duragesic (PA, QL)Esgic (QL)Euflexxa* (PA)Fentora (PA, QL)FexmidFlector (ST, QL)Gelsyn-3* (PA)Hyalgan* (PA)Ilaris* (PA)Lazanda (PA, QL)LidodermMaxalt (QL)Maxalt MLT (QL)MitigareMonovisc* (PA)Nucynta (PA, QL)Nucynta ER (PA, QL)Onzetra Xsail (QL)Orencia* (PA)Orthovisc* (PA)Otrexup* (PA)Oxaydo (PA, QL)Pennsaid (ST)Percocet (PA, QL)ProcortProctofoam-HCRelpax (QL)SavellaSubsys (PA, QL)Synvisc* (PA)
TIER 1$
TIER 2$$
TIER 3 $$$
PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
hydrocodone-acetaminophen (PA, QL)
hydromorphone (PA, QL)
hydromorphone ER (PA, QL)
ibuprofenindomethacinindomethacin ERketorolac (QL)leflunomidelidocaine 5% ointment (QL)
lidocaine viscouslidocaine-prilocaineLidoprilLidopril XRLiproZonePakLivixil PakLorcet (PA, QL)Lorcet HD (PA, QL)Lorcet Plus (PA, QL)Lortab (PA, QL)Medolor PakmeloxicamMetaxallmetaxalonemethocarbamolmorphine (PA, QL)morphine ER (PA, QL)
nabumetonenaproxennaproxen DSoxycodone (PA, QL)oxycodone ER (PA, QL)
oxycodone-acetaminophen
(PA, QL)oxymorphone (PA, QL)
oxymorphone ER (PA, QL)
PrilolidPrimlev (PA, QL)Profeno
Synvisc-One* (PA)Tremfya* (PA)UloricVoltaren (ST, QL)Xeljanz XR* (PA)Xeljanz* (PA)Zebutal (QL)Zohydro ER (PA, QL)
15
Cigna Advantage 3-Tier Prescription Drug List
TIER 1$
TIER 2$$
TIER 3 $$$
PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
Relador PakRelador Pak Plusrizatriptan (QL)sumatriptan (QL)tizanidinetramadol (QL)tramadol ER (QL)Verdrocet (PA, QL)Vicodin (PA, QL)Vicodin ES (PA, QL)Vicodin HP (PA, QL)zolmitriptan (QL)zolmitriptan ODT (QL)
PARKINSON’S DISEASE
amantadinebenztropinebromocriptinecarbidopa-levodopacarbidopa-levodopa ER
pramipexolepramipexole ERrasagilineropiniroleropinirole ER
Apokyn* (PA)AzilectMirapexMirapex ERNeuproRytarySinemetSinemet CRTasmarXadago
SCHIZOPHRENIA/ANTI-PSYCHOTICS
aripiprazolearipiprazole ODTchlorpromazinehaloperidololanzapineolanzapine ODTolanzapine-fluoxetine
paliperidone ERquetiapinequetiapine ERrisperidonerisperidone ODTziprasidone
Abilify Maintena (QL)Aristada (QL)Fanapt 12mg (ST)Fanapt (ST, QL)Invega Sustenna (QL)
Invega Trinza (QL)Latuda (ST)Rexulti (ST)Saphris (ST)Seroquel (ST)Seroquel XR (ST)Vraylar (ST)
SEIZURE DISORDERS
carbamazepinecarbamazepine ERclonazepamdivalproex
Dilantin 30mgLamictal XR start kit
Lyrica
AptiomBanzel (QL)BriviactCarbatrol
TIER 1$
TIER 2$$
TIER 3 $$$
SEIZURE DISORDERS (cont)
divalproex EREpitolgabapentinlamotriginelamotrigine ERlamotrigine ODTlevetiracetamlevetiracetam ERoxcarbazepineRoweepratopiramatetopiramate ER 50mg capsule
DepakoteDepakote ERDilantin 50mg, 100mg, suspension
FycompaKeppraKeppra XRLamictalLamictal ODTLamictal XR tabletOxtellar XRPhenytekQudexy XRSabril*SpritamTegretolTegretol XRTopamaxtopiramate ER (25mg, 100mg, 150mg, 200mg)
TrileptalTrokendi XRVimpat
SKIN CONDITIONS
acitretinadapalene (PA)Ala-Cort 2.5%Amnesteem (QL)AVAR cleanserAVAR-E creamBP 10-1calcipotrienecalcipotriene-betamethasone DP
CalcitreneClaravis (QL)Clindacin ETZClindacin Pclindamycinclindamycin-benzoyl peroxide
clindamycin-tretinoin
clobetasolClodan shampooclotrimazole-betamethasone
Aczone 7.5%EucrisaFluoroplexTargretin gel*
Aczone 5%Denavir (QL)Desonate (ST)Desowen (ST)DrysolDupixent* (PA)EcozaEfudexElidelExeldermFinaceaHydro 35Hydro 40NaftinNizoralPicatoSantyl (QL)SkliceSoolantraTaltz* (PA)TolakTopicort (ST)Tremfya* (PA)
16
TIER 1$
TIER 2$$
TIER 3 $$$
SKIN CONDITIONS (cont)
desonidedoxepineconazolefluocinonidefluorouracilhydrocortisoneimiquimodketoconazolemetronidazolemupirocinMyorisan (QL)Neuac gelnystatin-triamcinolone
oxiconazole nitratepermethrinProcto-Med HCProcto-PakProctosol-HCProctozone-HCRosadanRosanilScalacort lotionsulfacetamide-sulfurSSS 10-5SulfaCleanse 8-4tacrolimus ointmenttretinoin cream, gel (PA)
triamcinolone topical
TridermZenatane (QL)
Tridesilon (ST)UmectaUramaxinXolegel
SLEEP DISORDERS/SEDATIVES
armodafinil (PA)eszopiclonemodafinil (PA)temazepamzolpidemzolpidem ER
Belsomra (ST)Silenor (ST)
Rozerem (ST, QL)Xyrem* (PA)
SMOKING CESSATION
bupropion SR+
NicoDerm CQ+
Nicorelief+
nicotine gum+
nicotine lozenge+
nicotine patch+
Quit 2+
Quit 4+
Nicorette+
TIER 1$
TIER 2$$
TIER 3 $$$
SUBSTANCE ABUSE
buprenorphinebuprenorphine-naloxone
naloxonenaltrexone (QL)
BunavailNarcanProbuphineSuboxoneZubsolv
TRANSPLANT MEDICATIONS
azathioprine*mycophenolic acid*sirolimus*tacrolimus*
Prograf* Astagraf XL*Cellcept*Envarsus XR*Myfortic*Neoral*Zortress*
URINARY TRACT CONDITIONS
cevimelinedarifenacin ERdutasteridefinasterideoxybutynin oxybutynin ERphenazopyridinepotassium citrate ERtamsulosintolterodinetolterodine ERtrospium trospium ER
AvodartCystagon*ElmironJalynProcysbi* (PA)PyridiumRapafloThiola*
Cigna Advantage 3-Tier Prescription Drug List
17
Medications that are not covered
The medications listed below aren’t covered on your plan’s drug list.^^ This means that if you fill a prescription for any of these medications, you’ll pay the full cost of the medication. We want you to know your plan covers other medications that offer similar health outcomes.^^ We’ve listed some below. You should call your doctor’s office to talk about your options.
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
ALLERGY/NASAL SPRAYS Auvi-QEpiPen, EpiPen Jr
epinephrine auto injector
Beconase AQDymistaNasonexOmnarisQNASLZetonna
Generic nasal steroids (e.g., fluticasone)
QNASL Children budesonidefluticasonetriamcinolone
ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Aplenzin bupropion XL
Ativan lorazepam
Cymbalta duloxetine
Lexapro escitalopram
Pamelor nortriptyline
Parnate tranylcypromine
Pexeva paroxetine
Pristiq bupropion SR/XLduloxetinevenlafaxine ERAll generic SSRIs
Tofranil imipramine
Wellbutrin XL bupropion XL
ASTHMA/COPD/RESPIRATORY AerospanAlvescoArmonAir RespiClickArnuity ElliptaAsmanexAsmanex HFAFlovent DiskusFlovent HFAPulmicort Flexhaler
QVAR/QVAR Redihaler
Arcapta NeohalerSerevent Diskus
Striverdi Respimat
BevespiStiolto RespimatUtibron Neohaler
Anoro Ellipta
18
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
ASTHMA/COPD/RESPIRATORY (cont) Dulera Advair DiskusAdvair HFABreo Ellipta
Elixophyllin theophylline oral solution
Proventil HFAVentolin HFAXopenex HFA
ProAir HFAProAir RespiClick
Seebri NeohalerSpirivaSpiriva RespimatTudorza Pressair
Incruse Ellipta
Zyflo montelukastzafirlukast
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Cotempla XR-ODT dexmethylphenidate ERmethylphenidate ER/CD/LA
Desoxyn methamphetamine
Dexedrine dextroamphetamine
Mydayis dextroamphetamine ERamphetamine/dextroamphetamine ER
Vyvanse dexmethylphenidate ER dextroamphetamine-amphetamine ERmethylphenidate ER/LA
BLOOD PRESSURE/HEART MEDICATIONS Accupril quinapril
Accuretic quinapril-HCTZ
Altace ramipril
Atacand candesartan
Atacand-HCT candesartan-HCTZ
Avalide irbesartan-HCTZ
Avapro irbesartan
Azor amlodipine-olmesartan
Benicar olmesartan
Benicar HCT olmesartan-HCTZ
Betapace sotalol
Bystolic Generic beta blockers (e.g., metoprolol, atenolol)
Byvalson Generic ARBs + generic beta blockers
Cardizem diltiazem
Cardizem CD Cartia XTdiltiazem CD/ER
Cozaar losartan
Diovan valsartan
Diovan HCT valsartan-HCTZ
19
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
BLOOD PRESSURE/HEART MEDICATIONS (cont)
Edarbi Generic ARBs (e.g., losartan, valsartan)
Edarbyclor Generic ARBs + HCTZ (e.g., losartan-HCTZ)
Exforge amlodipine-valsartan
Exforge HCT amlodipine-valsartan-HCTZ
Hyzaar losartan-HCTZ
IsordilIsordil Titradose
isosorbide dinitrate
Lanoxin Digitek digoxin
Lotensin benazepril
Lotensin HCT benazepril-HCTZ
Lotrel amlodipine-benazepril
Micardis telmisartan
Micardis HCT telmisartan-HCTZ
PrinivilZestril
lisinopril
Tarka trandolapril-verapamil ER
Tekturna Generic ACE/ARBs
Tekturna HCT Generic ACE/ARBs + HCTZ
Tribenzor olmesartan-amlodipine-HCTZ
Twynsta telmisartan-amlodipine
Vaseretic enalapril-HCTZ
Vasotec enalapril
Zestoretic lisinopril-HCTZ
BLOOD THINNERS/ANTI-CLOTTING Yosprala IR or EC aspirin
CANCER Nilandron nilutamide
CHOLESTEROL MEDICATIONS Altoprev atorvastatinlovastatinrosuvastatinsimvastatin
AntaraFenoglide
fenofibrate
Crestor rosuvastatin
FlolipidZocor
simvastatin
Lescol XL 80mg fluvastatin ER
Lipitor atorvastatin
LivaloVytorin
atorvastatin rosuvastatinsimvastatin
Pravachol pravastatin
COUGH/COLD MEDICATIONS Tussicaps hydrocodone-chlorpheniramine ERpromethazine-codeine
20
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
DENTAL PRODUCTS Arestin minocycline/ER
DIABETES Accu-Chek, Contour, Freestyle, all other test strips and meters
OneTouch test strips and meters
AfrezzaApidraApidra SoloStarFiaspNovolin, Novolog
HumalogHumulin
FortametGlumetzametformin ER (generic Fortamet and Glumetza)
metformin ER (generic Glucophage XR)
InvokametInvokamet XR
Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga
JentaduetoJentadueto XRKazanoNesina
Janumet, Janumet XR
Kombiglyze XROnglyzaOseniTradjenta
alogliptinalogliptin-metforminJanuvia, Janumet, Janumet XR
LantusToujeo SoloStar
Basaglar, Levemir, Tresiba
QTERN Glyxambi
TanzeumVictoza
Trulicity
DIURETICS Edecrinethacrynic acid
bumetanidefurosemidetorsemide
EYE CONDITIONS AlocrilAlomide
cromolyn
BepreveEmadineLastacaftPatadayPatanolPazeo
azelastine epinastine olopatadine
Elestat epinastine
Lumigan bimatoprostlatanoprostTravatan Z
21
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
GASTROINTESTINAL/HEARTBURN Anusol-HC suppositoryCortifoamUceris foam
Anucort-HCHemmorex-HChydrocortisone suppository
Asacol-HDColazalDelzicolDipentumGiazomesalamine 800mg tablet
Apriso balsalazide LialdaPentasasulfasalazinesulfasalazine DR
Librax chlordiazepoxide-clidinium
Lotronex alosetron
Marinol dronabinol
Omeclamox-PakPrevpacPylera
lansoprazole-amoxicillin-clarithromycin (combo pak)
Rowasa mesalamine enema
Syndros dronabinol
Trulance Amitiza, Linzess
Zofran ondansetron
Zofran ODT ondansetron ODT
Zuplenz ondansetronondansetron ODT
HORMONAL AGENTS FortestaNatestoTestimVogelxo
AndroGel 1.62%testosterone
Cortrosyn cosyntropin
DDAVP desmopressin
DexpakZonacortZodex
dexamethasone
GenotropinNorditropinNutropin AQOmnitropeSaizenZomacton
Humatrope (PA)
Hectorol doxercalciferol
Rayos prednisoneprednisone intensol
Uceris tablet budesonide EC
22
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
INFECTIONS Acticlate DoryxMinocin capsuleMonodoxOracea Solodyn Vibramycin capsule Ximino
Generic products (e.g., doxycycline; mino-cycline)
Augmentin/ES/XR amoxicillin-clavulanate ER
Bethkis Tobi
Kitabis Paktobramycin
Diflucan fluconazole
E.E.S. 200Eryped 400
erythromycin ethylsuccinate
Mepron atovaquone
Mycobutin rifabutin
Onmel itraconazoleterbinafine
Sitavig acyclovir
Sporanox itraconazole
Targadox tobramycin
Valcyte valganciclovir
Vancocin vancomycin
Zovirax acyclovir
INFERTILITY BravelleGonal-F
Follistim AQ (PA)
MISCELLANEOUS Horizant gabapentin
MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera
PAIN RELIEF AND INFLAMMATORY DISEASE Amrix cyclobenzaprineOther generic muscle relaxants
Belbuca buprenorphine
Bupap butalbital-acetaminophen Tencon
Cambia diclofenac 1.5% dropsDuexis Naprelannaproxen CRnaproxen ERPennsaid Tivorbex Vimovo Vivlodex Zipsor Zorvolex
Generic prescription NSAIDs (e.g., celecoxib, meloxicam)
23
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
Conzip tramadol tramadol ER
D.H.E. 45 dihydroergotamine
Duzallo allopurinol, probenecid
Gralise gabapentin
ImitrexSumavel DoseProZembrace SymTouch
sumatriptan
Kineret SimponiSimponi Aria
Enbrel (PA)Humira (PA)Remicade (PA)Stelara (PA)
levorphanol Generic products (e.g., acetaminophen-codeine, hydromorphone, oxycodone)
Lorzone chlorzoxazone
Migranal dihydroergotamine
OxyContin Xtampza ER (PA)Embeda ER (PA)Hysingla ER (PA)
Roxicodone oxycodone
Sprix ketorolac
Treximet Generic NSAIDs Generic triptans (e.g., sumatriptan, naratriptan)
Vanatol LQ butalbital-acetaminophen-caffeine
Zomig zolmitriptansumatriptan
Zomig ZMT zolmitriptan ODT
PARKINSON’S DISEASE Gocovri amantadine
Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
FazacloVersacloz
clozapineclozapine ODT
Geodon ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
SEIZURE DISORDERS Mysoline primidone
SKIN CONDITIONS Absorica ClaravisMyorisanZenatane
24
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
SKIN CONDITIONS (cont) AcanyaAtralinAvitaAzelexDifferinDuacEpiduoEpiduo ForteFabiorOnextonRetin-ATazoracTretin-XVeltinZiana
tretinoinclindamycin-benzoyl peroxide
Aldara imiquimod cream
Anusol-HC cream hydrocortisoneProcto-Med HCProctosol-HCProctozone-HC
Bensal HP salicylic acid
Benzaclin DuacNeuac Kit
clindamycin-benzoyl peroxideNeuac gel
Carac fluorouracil
Clindagel clindamycin
Clobex clobetasol
Cutivate Generic topical steroid (e.g. betamethasone)
diclofenac 3% gelSolaraze
fluoroplexfluorouracilimiquimodPicato
DovonexSorilux
calcipotriene
EnstilarTaclonex
calcipotriene-betamethasone DP
ErtaczoExtinaLuzuVusion
ketoconazole
HalogUltravate X
clobetasolhalobetasol
JubliaKerydin
Ciclodanciclopiroxitraconazoleterbinafine
25
^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
DRUG CLASS MEDICATION NOT COVERED^^GENERIC AND/OR PREFERRED
BRAND ALTERNATIVES
SKIN CONDITIONS (cont) Kenalog triamcinoloneLocoidLocoid Lipocream
hydrocortisone
Loprox ciclopiroxNoritate metronidazole
RosadanOxistat clotrimazole
econazoleketoconazole
Penlac Ciclodanciclopirox
PrudoxinZonalon
doxepin
Sernivo betamethasonefluocinonidehydrocortisone
Siliq Enbrel (PA)Humira (PA)Remicade (PA)Stelara (PA)
Soriatane acitretinTrianex triamcinolone
TridermUltravate lotion clobetasolVanos fluocinonideVectical calcitriol ointmentVerdesoXerese
desonideacyclovirhydrocortisone
Zyclara imiquimod
SLEEP DISORDERS/SEDATIVES Ambien Ambien CREdluarIntermezzo
zolpidemzolpidem ER
Nuvigil armodafinilProvigil modafinilRestoril temazepam
SUBSTANCE ABUSE Evzio Narcan
URINARY TRACT CONDITIONS DetrolDetrol LADitropan XLEnablexGelniqueMyrbetriqOxytrolToviazVESIcare
darifenacin ERoxybutynin ER tolterodine ER trospium ER
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Prescription drug list FAQs
Understanding your prescription medication coverage can be confusing. Below are answers to some commonly asked questions.
Why do you make changes to the drug list?
Cigna regularly reviews and updates the prescription drug list. We make changes for many reasons – like when new medications become available or are no longer available, or when medication prices change. We try to give you many options to choose from to treat your health condition. These changes may include:1
› Moving a medication to a lower cost tier. This can happen at any time during the year.
› Moving a brand medication to a higher cost tier when a generic becomes available. This can happen at any time during the year.
› Moving a medication to a higher cost tier and/or no longer covering a medication. This typically happens twice a year on January 1st and July 1st.
› Adding requirements to a medication. For example, requiring approval from Cigna before a medication may be covered or adding a quantity limit to a medication.
It’s important to know that when a medication changes tiers or is no longer covered, you may pay a different amount to fill that medication.
Why doesn’t my plan cover certain medications?
To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand medications because they have lower-cost, covered alternatives which are used to treat the same condition. Meaning, the alternative works the same or similar to the non-covered medication. If you’re taking a medication that isn’t covered by your plan and your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
Your plan may also exclude certain medications or products from coverage. This is known as a “plan (or benefit) exclusion.” For example, your plan excludes:
› Medications that are available over-the-counter, without a prescription. These include medications commonly used to treat heartburn and stomach acid conditions (ex. Nexium, Prilosec and any generics) and allergies (ex. Allegra, Clarinex, Xyzal and any generics).
› Medications used to treat lifestyle conditions (like infertility, weight loss, erectile dysfunction, smoking cessation2).
› Medications that aren’t approved by the U.S. Food and Drug Administration (FDA).
Why aren’t some medications covered on my drug list?
Some high-cost medications have clinically appropriate alternatives. Meaning, they work the same or similar to another covered prescription medication or over-the-counter (available without a prescription) alternative. To help lower your overall health care costs, these high-cost medications are not covered. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
We also do not cover medications that aren’t approved by the U.S. Food and Drug Administration (FDA).
How do you decide which medications are covered?
The Cigna Prescription Drug List is developed with the help of Cigna’s Pharmacy and Therapeutics (P&T) Committee, which is a group of practicing doctors and pharmacists, most of whom work outside of Cigna. The group meets regularly to review medical evidence and information provided by federal agencies, drug manufacturers, medical professional associations, national organizations and
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peer-reviewed journals medications about the safety and effectiveness of medications that are newly approved by the FDA and medications already on the market. The Cigna Pharmacy Management® Business Decision Team then looks at the results of the P&T Committee’s clinical review, as well as the medication’s overall value and other factors before adding it to, or removing it from, the drug list.
Which medications are covered under the health care reform law?
The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. Under this law, certain preventive medications (including some over-the-counter medicines) may be available to you at no cost-share ($0), depending on your plan. Log in to the myCigna website or app or check your plan materials to learn more about how your plan covers preventive medications. You can also view the PPACA No Cost-Share Preventive Medications drug list on Cigna.com/druglist.
For more information about health care reform, visit www.informedonreform.com or Cigna.com.
Are medications newly approved by the FDA covered on my drug list?
Newly approved medications may not be covered on your drug list for the first six months after they receive FDA approval. These include, but are not limited to, medications, medical supplies or devices covered under standard pharmacy benefit plans. We review all newly approved medications to determine if they should be covered – and if so, at what tier level. If your doctor feels a currently covered medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the newly approved medication.
How can I find out how much I’ll pay for a specific medication?
Use the Drug Cost tool on the myCigna website or app to estimate how much your medication may cost3 and view lower cost alternatives, if available.
How can I save money on my prescription medications?
You may be able to save money by switching to a medication that’s on a lower tier (ex. generic or preferred brand) or by filling a 90-day supply, if your plan allows. Talk with your doctor to find out if one of these options, may work for you.
What’s the difference between brand name and generic medications?
The FDA requires generic equivalent medications to have the same quality and performance as brand name medications. A generic equivalent medication is the same as a brand name medication in dosage form, active ingredient, strength, route of administration, quality, performance characteristics and intended use. Generics typically cost much less than brand name medications – in some cases, up to 80%–85% less.4 Just because generics cost less than brands, it doesn’t mean they’re lower-quality medications.
How can I get help with my specialty medication?
Cigna Specialty Pharmacy ServicesSM can help you manage your health and prescription needs. Our therapy management teams, made up of pharmacists and health advocates with nursing backgrounds, provide personalized, 24/7 support. They’ll help you get approval for coverage of your medication, make sure your medication is the right dose, help you work through any side effects, make sure you have any supplies you need, set up the delivery of your medication through Cigna Specialty Pharmacy (our home delivery pharmacy) and give you information about the financial assistance programs available (if you need help paying for your medication).
Call 800.351.3606 if you have questions or need help transferring your prescription. To learn more about the services they provide, you can also go to cigna.com/specialty-pharmacy-services.
Prescription drug list FAQs (cont)
Prescription drug list FAQs (cont)
Can I fill my prescriptions by mail? If you take a medication every day to treat an ongoing health condition (like diabetes, high blood pressure, high cholesterol or asthma), you can order up to a 90-day supply through Cigna Home Delivery Pharmacy.SM 5 To get started, call 800.835.3784. To learn more about the services they provide, go to cigna.com/home-delivery-pharmacy.
If you’re taking a specialty medication to treat a complex condition like multiple sclerosis, hepatitis C and rheumatoid arthritis, you can fill your prescription through Cigna Specialty Pharmacy (our home delivery pharmacy).5 To get started, call 800.351.3606. To learn more about the services they provide, go to cigna.com/specialty-pharmacy-services.
Where can I find more information about my prescription medication plan?
Use the online tools and resources on the myCigna website or app to help you better understand and manage your pharmacy benefits. You can view your drug list or search for a specific medication, use Drug Cost tool to estimate how much your medications may cost, find an in-network pharmacy near you, review your pharmacy claims and payment history, and fill and track your home delivery orders.
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› over-the-counter (OTC) medications (medications that do not require a prescription) except insulin unless state or federal law requires coverage of such drugs;
› prescription drugs or supplies for which there is a non-prescription or OTC therapeutic alternative;
› physician-administered injectable medications covered under the Plan’s medical benefit, unless otherwise covered under the Plan’s prescription drug list or authorized by Cigna;
› implantable contraceptive devices covered under the Plan’s medical benefit;
› medications that are not medically necessary;
› experimental or investigational medications, including FDA-approved drugs used for purposes other than those approved by the FDA unless the drug is recognized for the treatment of the particular indication;
› medications that are not approved by the Food & Drug Administration (FDA);
› prescription and non-prescription devices, supplies, and appliances other than those supplies specifically listed as covered;
› medications used for fertility, sexual dysfunction, cosmetic purposes, weight loss, smoking cessation, or athletic enhancement;
› prescription vitamins (other than prenatal vitamins) or dietary supplements unless state or federal law requires coverage of such drugs;
› immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis;
› replacement of prescription drugs and related supplies due to loss or theft;
› drugs which are to be taken by or administered to a covered person while they are a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals;
› prescriptions more than one year from the date of issue; or
In addition to the plan’s standard pharmacy exclusions, certain new FDA-approved drug products (including, but not limited to, medications, medical supplies or devices that are covered under standard pharmacy benefit plans) may not be covered for the first six months of market availability unless authorized by Cigna as medically necessary.
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain preventive prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, the prescription may not be covered. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements.
Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan:6
Exclusions and limitations
1. State laws in Texas and Louisiana require health insurance plans to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can’t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card.
2. Smoking cessation medications are not typically covered under the plan, except as required by law or by the terms of your specific plan. Costs and complete details of the plan’s prescription drug coverage, including a full list of exclusions and limitations, are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence.
3. Prices are not guaranteed, and even though a price is displayed in the Drug Cost tool, it’s not a guarantee of coverage. Your costs and coverage may change by the time you fill your prescription at the pharmacy, and medication costs at individual pharmacies can vary. Coverage and pricing may change. For example, your pharmacy’s retail cash price for a specific medication may be less than the price shown in the Drug Cost tool.
4. U.S. Food and Drug Administration (FDA) website, “Facts About Generic Drugs.” Last updated 06/28/16.
5. Plans vary, so some plans may not include Cigna Specialty Pharmacy or Cigna Home Delivery Pharmacy. Please check your plan materials for more information on what pharmacies are covered under your plan.
6. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., Tel-Drug, Inc., and Tel-Drug of Pennsylvania, L.L.C. “Cigna Specialty Pharmacy Services” and “Cigna Specialty Pharmacy” refer to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. Policy forms: OK - HP-APP-1 et al (CHLIC); TN - HP-POL43/HC-CER1V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
887152 k Advantage 3-Tier w DRT 03/18 © 2018 Cigna. Some content provided under license.
Cigna reserves the right to make changes to the Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.